Vana: The G20's Global Health Governance, 2008-2018

I am grateful for the contribution of John Kirton and the assistance and data of members of the G20 Research Group.

Introduction

Significance

Global health governance is a relatively new field of discussion within global summit governance. It has risen to prominence due to drivers such as pandemics that are exacerbated by globalization, urbanization and climate change. Global health governance refers to "the use of formal and informal institutions, rules, and processes by states, intergovernmental organizations, and non-state actors to deal with health challenges that require cross-border collective action" (Fidler 2010). Global health policies encompass many health challenges such as severe acute respiratory syndrome (SARS); Middle East respiratory syndrome (MERS); influenza A (H1N1); HIV/AIDS, tuberculosis and malaria; antimicrobial resistance (AMR); Ebola; non-communicable diseases (NCDs); Zika virus; the migration of health workers from developing to developed countries; and the social determinants of health. Therefore, health is a multidimensional subject that is in need of exploring further to determine preventative solutions. The economic and fiscal challenges continue with the global health governance gaps that are not being addressed. This makes it a task for the G20 (Kirton and Hospedales 2016).

Global health governance has been transformed by multilateral global health organizations, notably the World Health Organization (WHO) (Kirton and Mannell, 2007). The shift was initiated by the WHO at its peak strength during the 1970s through its ambitious human rights initiative for "Health for All" (Kirton and Mannell, 2007). The WHO defines health as "the state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (Fidler 2010). However, with the outburst and rapid spread of HIV/AIDS in the 1980s and 1990s, the WHO proved inadequate in addressing this challenge. Its failure fuelled a search for improvement in the global health governance through the introduction of other international institutions.

The intensified cross-border health problems that have arisen have become a growing concern. Domestic action for the prevention of pandemics, infectious and non-communicable diseases is no longer sufficient. Due to interdependence, countries are unable to take care of their own health epidemics. Therefore, it has become an urgent matter on the international stage. Millions of people in G20 countries are infected each year by microbes susceptible to the development of resistance (Organisation for Economic Co-operation and Development [OECD], WHO, Food and Agriculture Organization [FAO] and World Organisation for Animal Health [OIE] 2017). Good health governance among and beyond G20 countries has become increasingly more difficult to achieve because there has been no consistent attention to health within the G20 summits from 2008 to 2018.

Contributors to the challenges of global health governance from a moral standpoint arise in relation to poverty, inequality and socioeconomic status. The outbreak of pandemic influenza A (H1N1) found countries unable to access vaccines for treatment (Fidler 2010). Although globalization has created unprecedented wealth within developed countries, political, economic, social and environmental factors shape how infectious disease, epidemics or pandemics emerge or spread (Fidler 2010). For example, climate change is one of the factors harming human health that disproportionately affects the poor because poverty is one of the most robust determinants of poor health outcomes.

On a more pragmatic level, health, being on the G20 summit agenda sparingly since the first Washington Summit in 2008, and then gaining more recognition at the St. Petersburg Summit in 2013, has played a significant role in shaping the G20's legitimacy and effectiveness towards pandemics and epidemics on a domestic and international scale. Since the G20 was elevated from the forum of finance ministers and central bank governors to the level of leaders in 2008, both explicitly and indirectly, G20 summits have governed health, with a surge in 2013 (Kirton, Bracht and Kulik 2015). At the 2014 Brisbane Summit the international response to the Ebola outbreak revealed that the world as well as the G20 needed to recognize and prioritize the humanitarian, social and economic impacts of epidemics in developing countries. The failure of international institutions such as the WHO and the G7 led the G20 to fill the global health governance vacuum.

The Debate among Competing Schools of Thought

The course, causes and consequences of G20 health governance have prompted a debate among several competing schools of thought.

The first school sees steadily increasing involvement by the G20 since the 2008 Washington Summit (Kirton, Bracht and Kulik 2015). As a variant the economic and fiscal burden of global health, combined with the global health governance gaps not being addressed elsewhere, make health governance a task that is tailor-made for the G20 (Kirton, Bracht and Kulik 2015).

The second school sees substantial shock-driven compliance as the G20 has increasingly dealt directly with health, with a great surge of attention to the infectious disease of Ebola at its ninth summit in 2014 (Kirton and Hospedales 2018).

The third school sees systemic hub governance as essential to the performance of the G20. It argues that G20 health performance has grown across a widening, more demanding, more domestically intrusive agenda (Kirton 2013). Kirton, Kulik and Bracht (2014) argue that the G20 is the only institution able to adequately governance gaps not addressed elsewhere.

The fourth narrow-targeted school argues that the G20 addresses specific global health risks, focusing on improving WHO operations, increasing health risk surveillance and securing the development of medicines and vaccines that predominantly benefit the poor (Sainsbury and Wurf (2015). Sainsbury and Wurf (2015) explore the potential for the G20 to address the gaps in global health governance. Cross-border health security adds an important dimension to long-term economic resilience, and an agenda that narrowly targets health risks would be a sensible use of G20 time and energy (Sainsbury and Wurf 2015).

The fifth school sees strong shock-activated performance against acute outbreaks due to the failure of the WHO. With the world looking towards the WHO as a reliable source to deal with the outbreak of epidemics, the 2014 Ebola crisis proved this wrong. It instigated a shock-activated performance, as a result of the WHO being ill-prepared to address any global, sustained health emergency (Sainsbury and Wurf 2015).

The sixth school sees promising potential for comprehensive health governance (Gostin et al. 2016). The Ebola epidemic gave rise to four global commissions proposing a bold new agenda for global health preparedness and response for future infectious disease threats: the WHO Ebola Interim Assessment Panel, the Harvard University and the London School of Hygiene and Tropical Medicine's Independent Panel on the Global Response to Ebola, the Commission on a Global Health Risk Framework for the Future convened by the US National Academy of Medicine, and the United Nations High-Level Panel on the Global Response to Health Crises (Gostin et al. 2016). The commissions were established to critically evaluate the national and global response to Ebola to enhance preparedness to prevent, detect and respond to future infectious disease threats. These four commissions succinctly agreed that political attention to global health security could no longer be episodic, limited to when an epidemic strikes (Gostin et al. 2016). It must be sustained by standing agendas on health security by the G20. Therefore, global leaders including the United Nations, the World Health Assembly, the G7 and the G20 should maintain continuous oversight of global health preparedness, and ensure effective implementation of the Ebola commissions' key recommendation, including sustainable and scalable financing (Gostin et al. 2016).

Puzzles

Most of the literature on the G20's global health governance is relatively dated. It misses crucial new information from more recent summits, especially those after the 2008 Washington Summit where only 118 words regarding health appeared in the outcome document (G20 2008). None of the studies thus far include a comprehensive review of G20 summits' health governance and their performance on addressing the topic, until the 2013 St. Petersburg Summit, which produced 1,340 words on health (G20 2013). A major puzzle in global health governance, as Kirton and Hospedales (2016) have suggested, is the WHO's role in responding to major world epidemics where it has failed. For cross-border issues, the WHO created a legal framework of International Health Regulations (IHRs) in 2005. Adopted in 2007, the IHRs were designed to prevent the international spread of disease. They were also intended to act as a global safety net in the event of an infectious disease outbreak or other health threat (Kirton and Hospedales 2016). However, WHO efforts to address the Ebola crisis in 2014 were unreasonably slow. Therefore, the G20 had to intervene. The Ebola epidemic highlighted the importance of cross-border health security to long-term economic resilience (Sainsbury and Wurf 2015).

This study fills these gaps by providing a more complete and systematic analysis of what the G20 did on health from 2008 to 2018, how well it performed along the six major dimensions of governance, the contribution of the six causal factors of the systemic hub model of G20 governance and how critical summits notably, the 2013 St. Petersburg Summit, 2014 Brisbane Summit and the 2017 Hamburg Summit governed (Kirton 2013).

Thesis

This study argues that G20 health governance has increased in prominence and expanded in scope on a global level. The G20 supported international organizations such as the WHO, after the latter failed in responding to the 2014 Ebola crisis. The pattern of performance is well demonstrated by the G20's 2014 Brisbane Summit response to the Ebola crisis and to AMR. This contribution is a significant but still incomplete success in global health governance.

There are two distinct phases of G20 health governance. The first phase, from the 2008 Washington Summit to the 2013 St. Petersburg Summit, shows no or very low engagement, as there was virtually no commitment on health. During this phase, health was a minimal concern on the G20 summit agenda. Therefore, deliberation was very low until the 2014 Brisbane Summit, where it then soared due to the Ebola outbreak and the WHO's lack of commitment and preparedness to address the issue. The years between 2008 and 2013 saw an inconsistent pattern in deliberations and virtually no health commitments made on health.

The second phase of increasing, expanding engagement from the 2014 Brisbane Summit to the 2018 Buenos Aires Summit saw substantial growth in deliberation, commitment and compliance compared to the first phase. During this second phase, most dimensions of performance consolidated at a solid level, while the scope of the G20's agenda expanded in deliberations as well in commitments. The 2014 Brisbane Summit had a substantial increase in the number of deliberations and commitments on global health. Then, the 2017 Hamburg Summit had a substantial increase in the number of deliberations as well as commitments.

The major causes of the G20's increasingly prominent, expansive, WHO-supportive health governance are those highlighted by the systemic hub model of G20 governance (Kirton 2013).

The G20 responded to the shock of the acute outbreak of disease in the 2014 Ebola crisis in the wake of the WHO's failure in response, in the 2014 Brisbane Summit's surging performance to fill the governance vacuum. Sainsbury and Wurf (2015) argue that when a rapidly spreading global health risk threatens the confidence and stability of the global economy, the G20 responds in its role as a crisis management forum.

Importantly, the second shock-activated vulnerability arose during the second phase at the 2017 Hamburg Summit. Chancellor Angela Merkel put health as a priority on the agenda for the first time, with AMR a large topic. G20 leaders suggested strengthening public awareness, infection prevention, control and improving the understanding of the issue of AMR in the environment (G20 2017). Here, the WHO was present and addressed the importance of fostering research and development for priority pathogens. The WHO had also been in collaboration with the Organisation for Economic Co-operation and Development (OECD) on this facilitation (G20 2017).

Performance Patterns — Dimensions of Performance

G20 summit performance can be assessed in several ways, especially by the commitments that summits make and the compliance of members with those commitments that have been assessed by the G20 Research Group. The G20's health performance has passed through two phases. The first was very low from 2008 to 2013. Then there was a spike in deliberation during the St. Petersburg Summit in 2013 and a substantial increase to a significant level from 2014 to 2018. There was a second spike in deliberation to a historic high at Brisbane in 2014 and another spike at the Hamburg Summit in 2017. The resulting pattern highlights several changes: health became a priority on the G20 leaders' summits starting from the 2014 Brisbane Summit and gained more attention at the 2017 Hamburg Summit by addressing health strengthening and AMR, before dropping in 2018.

Deliberation (Public Conclusions and Private Conversation)

According to the G20's public deliberations, as outlined in the conclusions contained in the G20 communiqués, health including the Millennium Development Goals (MDGs) has been addressed at all summits since the first in Washington in 2008 (see Appendix A and Appendix B). The G20's public deliberation had two spikes. The first was at the 2010 Seoul Summit with 643 words for the first rise. There was the largest increase in words on health within the first half of the first phase. It then further soared to 1,340 words or 11.2% at the 2013 St. Petersburg Summit, which was the highest ever. It then steadily decreased to 769 words at the 2014 Brisbane Summit and to 707 words at the 2017 Hamburg Summit. Then came a sharp decrease to 316 words at the 2018 Buenos Aires Summit (see Appendix B).

This suggests two phases of deliberation. The first phase saw a steady rise from 2008 at the Washington Summit to the 2013 St. Petersburg Summit. The second saw a steady decline from the 2014 Brisbane Summit to the 2018 Buenos Aires Summit, interrupted only by the short increase at the 2017 Hamburg Summit with 707 words.

Domestic Political Management

Domestic political management is most easily measured by the number of communiqué compliments, or positive references to a country or leader in a health-related context. There was only one on health. It came at the 2012 Los Cabos Summit, which was in the first phase (see Appendix B).

Direction Setting

Preserving financial stability is the G20's first distinctive foundational mission. There were no affirmations of financial stability in regard to health from 2008 to 2018 (see Appendix B).

Making globalization work for all is the second distinctive foundation mission. The G20 experienced a weak start here with no affirmation of the principle of globalization in the first three summits in 2008 and 2009. There was one reference at the 2010 Toronto Summit and then two at the St. Petersburg Summit. There was a continuous pattern of either one or two affirmations through to the 2018 Buenos Aires Summit, which had two. This suggests two phases. Within phase one, there was virtually nothing. Within phase two, affirmations had a delay until a surge at to two at the 2013 St. Petersburg Summit.

Decision Making

Decision making refers to the commitments made on health. This dimension is assessed quantitatively as well as qualitatively.

The first 13 summits produced 61 health commitments for an average of 4.8 per summit (see Appendix B). Health thus ranked 13th among the 18 subjects that the G20 made commitments on (see Appendix C).

G20 health decision making passed through three phases. Starting at the 2008 Washington Summit there were virtually no commitments on health until 2011 (see Appendix B). There was then only one commitment each at the 2011 Cannes Summit and 2012 Los Cabos Summit, and two at the 2013 St. Petersburg Summit. The second phase started at the 2014 Brisbane Summit with a jump to 33 commitments. In the third phase, there was a decline after this peak, another surge to 19 commitments at the 2017 Hangzhou Summit and then four commitments at the 2018 Buenos Aires Summit.

Delivery

Delivery of these decisions by the members is measured by their compliance with the commitments during the time until the subsequent summit is held as assessed by the G20 Research Group.

Compliance was vastly different than the pattern in three phases of decision making. The 11 compliance assessments covered only six summits (see Appendix B). One had negative compliance and the rest had positive compliance. Some of the commitments assessed involved the MDGs as three of its eight goals were on health.

Within the first phase, the first summit to receive a compliance assessment was the 2009 London Summit. It received a compliance score of −0.05 or −53% (see Appendix B). The 2009 Pittsburgh Summit had compliance of +0.41 or 71%. The increase in compliance came despite adverse impact of the global crisis on the capacity of low-income countries to protect critical core spending in areas such as health (see Appendix A). The 2009 Pittsburgh Summit had the third highest percentage of the six summits with compliance score. At the 2010 Seoul Summit, compliance significantly dropped to +0.19 or 60%.

In the second phase there was substantial growth in compliance. At the 2014 Brisbane Summit compliance was +0.53 or 77%, based on four compliance assessments (see Appendix B). This included improving workplace safety and health (G20 2014b). Compliance then steadily decreased to +0.30 or 65% and then saw a major surge to the peak of +0.95 or 98%.

Overall, compliance with the 11 assessed commitments was a solid +0.39 or 70% (see Appendix B). This was marginally lower than the G20 summits' average compliance with all assessed commitments across all subjects of +0.41 or 71%.

Development of Global Governance

The G20 summits' guidance of institutions inside the G20 steadily increased in the first phase from 2010 to 2013. The 2010 Seoul Summit committed to reforms to strengthen social safety nets such as public health care (G20 2010).  This included involving the G20 Employment Working Group, the OECD, the International Monetary Fund (IMF) and the World Bank Group in making safety a health priority. This summit also improved the Seoul Summit's Mutual Assessment Process to promote external sustainability as well as the Seoul Action Plan. The highest number of references to developing global governance inside the G20 came at the 2013 St. Petersburg Summit (see Appendix B).

During the second phase (2014-2017), the number of institutions outside the G20 arose. This phase, starting with the 2014 Brisbane Summit, had the largest number of governance mechanisms outside of the G20, as a total of nine (see Appendix B). This summit invited the United Nations, the WHO, the World Bank Group and the IMF to support countries affected by the recent Ebola outbreak and supported the WHO's implementation of the IHRs (G20 2010).

Distinctive Mission Done

This dimension of performance measures how well the G20 achieved its distinctive mission of promoting financial stability and ensuring that globalization worked to the benefit of all (Kirton et al. 2019). This builds on and extends the earlier direction-setting dimension by adding the component of results. This dimension assesses actual accomplishments or distinctive mission done, seeking to measure how successfully these missions were achieved (Kirton et al. 2019).

On global health governance, the most relevant distinctive G20 mission is globalization for the benefit for all. One way to measure this is through global trends in inequality and human development. For financial stability, none of the outbreak health problems endangered global financial stability.

Globalization has acted as an accelerator and as a dispersion agent to expand and distribute wealth and poverty in new patterns and ways (Massey 2019). Within countries, global inequality has risen and the absolute number of people living in extreme poverty has also risen (Gruen, O'Brien and Lawson 2002). However, in other ways global inequality has decreased. There has been an acceleration in economic growth in the world's most populous countries such as the Asian countries of China and India. These countries, being considered the world's poorest, have accelerated and grown per capita (Gruen, O'Brien and Lawson 2002). Between 1981 and 2005, before G20 leaders began meeting, the number of people living in extreme poverty declined by 505 million due largely to the economic growth in China (Labonte, Mohindra and Schrecker 2010).

Deaths Delayed

The eighth dimension is deaths delayed. This is an outcome-oriented dimension that refers to the number of deaths that were delayed or prevented due to the G20's work on health governance. It is possible to assess on a deadly disease-specific basis, in case of extreme outbreak events.

In the case of the 2014 Ebola outbreak, three countries in Western Africa were affected – Liberia, Sierra Leone and Guinea. It had a large impact on these population. Based on the statistics given by the Centers for Disease Control and Prevention (CDC 2019) there was no decline in deaths from 2014 to 2016, despite the G20 Brisbane Summit's 33 health commitments, focused on Ebola, in November 2014. In Guinea, the number of deaths from November 2014 to 2016 increased from 59 to 2,544 people. In Liberia, the number of deaths from 2014 to 2016 increased from six to 4,810. In Sierra Leone deaths increased from five to 3,956. The Public Health Emergency of International Concern related to Ebola in West Africa was lifted on 29 March 2016. A total of 28,616 confirmed, probable and suspected cases, with 11,310 deaths, had been reported in Guinea, Liberia and Sierra Leone. However, preventative measures were taken in order to prevent the total amount of cases associated with the Ebola virus to be eradicated. In Guinea, total cases were 3,814 though deaths were 2,544; in Liberia there were 10,678 cases and 4,810 deaths; in Sierra Leone total cases 14,124 and 3,956 deaths.

However, there is some evidence suggesting G20 effectiveness in helping save lives. Since the beginning of the Ebola crisis in Guinea between March 2014 and January 2015 there was an increase of 165% (CDC 2019). In Guinea between January 2015 and April 2016 there was a decrease of 76.3%. In Liberia, between March 2014 and January 2015 the death rate increased by 349.6%. Yet between January 2015 and April 2016 the death rate decreased to 131.4%. In Sierra Leone, between March 2014 and January 2015, there was a 294.4% increase, whereas from January 2015 to April 2016 the rate decreased to 100.3%.

To conclude, the deaths rates drastically increased from 2014 to 2015 though decreased from 2015 to 2016.

Causes of Performance

The G20 summit health performance is well accounted for by the systemic hub model of G20 governance and its six causes of shock activated vulnerability, multilateral organizational failure, predominant and equalizing capability, converging characteristics and principles, domestic political cohesion and the G20 as cherished hub of a global governance network (Kirton 2013).

Shock-Activated Vulnerability

Shock-activated vulnerability was highly salient. The achievements made of 2014 Brisbane Summit were due in large part to the shock-activated vulnerabilities that year. The spread of the endemic infection of the 2014 Ebola crisis that spread through three West African countries of Liberia, Guinea and Sierra Leone was a communiqué-recognized shock on two accounts and as a vulnerability on one account (see Appendix D). This crisis caused various recommendations on changing structures, processes and instruments in responding to disease outbreaks, some of which were implemented. The G20 recognized the contributions of worldwide multilateral institutions such as the United Nations and its bodies such as the WHO (G20 2014a). The G20 (2014a) urged the World Bank Group and the International Monetary Fund (IMF) to continue its support to the affected countries and to make further donations of $300 million to stem the Ebola outbreak in the three countries affected. This outbreak illustrated the urgency of addressing longer-term systemic issues and gaps in capability and preparedness to respond in capacity that exposed the global economy to the impacts of infectious disease. The context of the G20's broader efforts to support others to implement the IHRs was to build capacity to prevent, detect a three-year lag, and report early and respond to infectious diseases such as the Ebola crisis.

Because of this crisis, the 2017 Hamburg Summit was the first time that health was at the centre of the summit agenda (Poust 2017). The fundamental priority at Hamburg was securing sustainable growth, with functioning health systems now seen as a prerequisite for security against the spread of diseases.

In conclusion, the pattern within shocks and vulnerabilities (see Appendix D) shows distinct phases of when the Ebola crisis was on the leaders' agenda at the summits. The 2013 St. Petersburg Summit had two recognized shocks and four vulnerabilities (see Appendix A). In 2014, at the Brisbane Summit, there were two references to shocks and only one to vulnerability. This suggests that the Ebola crisis did cause a shock. The 2017 Hamburg Summit had the second highest amount references to shocks—a total of three.

Multilateral Institutional Failure

Multilateral organizational failure, above all that of the WHO, was a second salient causal contribution. The WHO is at the centre of global health efforts. If regional and national health systems and organizations are the foundation for global health security, the WHO is at the apex. The shock of the 2004 SARS outbreak received large political attention from the WHO and the IHRs. The transformation of the global health strategy after SARS helped prepare the world for future outbreaks. This was supposed to fuel attention for the WHO to react to the Ebola crisis as well as it had to the SARS outbreak (Fidler 2015). Yet action taken by the WHO and the IHR with the outbreak of Ebola had little similarity.

The G20 had become involved at the outbreak of the Ebola crisis, yet the crisis had exposed deep problems with the WHO's funding, structure and staff, which had contributed to the international organization's inability to meet its obligations in preventing and stopping the outbreak. The WHO had responded too slowly to the outbreak, lacked the capabilities to mount effective responses once it understood the scale of the problem, and lost credibility as a global health leader within and beyond the United Nations (Fidler 2015). The Ebola outbreak exposed the WHO's neglect of global health security along with the institution's inability to function effectively. Médecins Sans Frontières (MSF) expressed its concern about the WHO's failure to address the Ebola crisis. It argued that there was no functioning global response mechanism to a potential pandemic in countries with fragile health systems, including Guinea, Liberia and Sierra Leone (Fidler 2015). The outbreak also underscored the lack of progress in improving compliance with the IHRs on national response and surveillance capacities. The Ebola outbreak overwhelmed the WHO and the IHR, leading these international institutions to failure in addressing the issue and the G20 to fill the global gap.

The G7 summit had also failed. It had been accused by the head of MSF for its lack of urgency over the Ebola crisis (Hussain 2015). During the G7 Elmau Summit on 7-8 June 2015 in Germany, Chancellor Angela Merkel touched upon the Ebola crisis, although no emphasis was put on the disease on the summit agenda. Topics with emphasis during the summit were climate change, foreign trade, plastic waste and female empowerment (Connolly 2015). The UN's financial tracking system showed that the scale of giving among G7 states to combat Ebola varied. While the United States contributed about 45% of the total Ebola budget, the United Kingdom gave 10% and Italy 0.3% (Connolly 2015).

Success

Other multilateral organizations were more successful in their response, if in selective way. The World Bank, which is a G20 member, made large contributions, starting with $200 million in August 2014, and having total funding exceed $1.6 billion by April 2015 (Gostin and Friedman 2015). These grants and loans extended beyond the direct Ebola response to include rebuilding health systems, social safety nets and agriculture.

In September 2014, the UN assumed leadership in Ebola response as the WHO failed to address the outbreak. The Security Council declared an outbreak a "threat to international peace and security," and because of this directed states to lift border and travel restrictions (Gostin and Friedman 2015).

Predominant Equalizing Capability

Globally predominant and internally equalizing capabilities and connectivity also help explain why these particular members act successfully in a group at Brisbane in 2014 to address the Ebola crisis. These 20 members gave the G20 the critical collective predominance and increasingly internal equality in the relative specialized health and financial capabilities of its systemically significant members that its international organizational and institutional alternatives lacked.

The increasing rise of medical doctors in each member country from 2014 to 2016 brought more predominant and equalizing capability to the G20 (see Appendix E). From 2014 to 2016 almost all G20 countries had a substantial increase in doctors (OECD 2019). In 2014, Australia had 3.4 doctors per 1,000 inhabitants; the number increased in 2016 to 3.6. In 2014, Canada had 2.6 doctors per 1,000 inhabitants, which increased in 2016 to 2.7. In 2014, China had 1.7 doctors per 1,000 inhabitants, then increased in 2016 to 1.8. In 2014, France had 3.3 doctors per 1,000 inhabitants, then increased in 2016 to 3.4. Germany had a slight increase of doctors from 2014 with 4.1 per 1,000 inhabitants to 2016 with 4.2. Italy had an increase from 3.8 in 2014 doctors per 1,000 inhabitants to 4.0 in 2016. Japan in 2014 had an increase of doctors per 1,000 inhabitants from 2.4 to 2.43 in 2016. In 2014 Mexico had an increase of doctors from 2.2 per 1,000 inhabitants to 2.3 in 2016. In 2014, the United Kingdom saw a slight increase in doctors from 2.7 per 1,000 inhabitants to 2.8. However, Russia saw a decline in doctors from 4.2 per 1,000 inhabitants to 3.9 in 2016.

In overall health expenditures, 17 of the G20 countries appeared on the Human Development Index. From 2013 to 2014 there was inconsistency in the countries' contributions to health expenditure. Argentina, Italy and Indonesia remained the same from 2013 to 2014. Canada, India, Mexico, Turkey and the United Kingdom all had declining health expenditures from 2013 to 2014. The rest of the G20 countries — the United States, South Africa, Russia, South Korea, Germany, France, China, Brazil and Australia — had rising health expenditures from 2013 to 2014 (United Nations Development Programme 2018). The majority of the G20 countries had an increase in health expenditures, making this performance in relative capability contribute to an explanation of the increasing and expanding engagement of the G20 with health during this time.

Domestic Political Cohesion

The fifth cause of G20 performance is domestic political cohesion. It posits that the G20's ability to govern health is contingent on the political capital control and support that G20 leaders have at home. Importantly, in order for G20 leaders to be able to implement and promote global health governance at a summit, a leader is generally more supportive of national efforts if they themselves have experienced health problems or have expertise in the field such as medicine. Citizens are thus generally supportive of national efforts if a leader has publicly known health-related issues. None of the G20 leaders has studied or practised medicine. German chancellor Angela Merkel, before becoming involved in politics, obtained a doctorate in quantum chemistry and worked as a research scientist. Several G20 leaders have experienced illness or disease themselves or their immediate family members have done so. There were three phases during which G20 leaders had publicly known illness or disease.

The first spike in health performance was at the 2013 St. Petersburg Summit. Argentinian president Cristina Fernández Kirchner revealed that she had been diagnosed with thyroid cancer and underwent surgery in 2012; doctors later found that it was a misdiagnosis and she did not have cancer (Bronstein and Rizzi 2012). Kirchner had to undergo surgery again in 2013 to remove blood from under a membrane covering her brain caused by a head injury (Guardian 2013). Brazilian president Dilma Rousseff had been treated for lymphoma, a cancer in the lymphatic system, in 2009 (Flor and Winter 2012). Canadian prime minister Stephen Harper had been treated for his severe case of asthma (CBC News 2006).

The second spike in health was at the 2014 Brisbane Summit where the main focus of the summit was the outbreak of the Ebola crisis. Dilma Rousseff attended with her knowledge of cancer, as did Stephen Harper with his history of asthma. Saudi Arabia's King Salman Abdulaziz Al Saud suffered from mild dementia, specifically Alzheimer's disease (Riedel 2017).

The third spike was at the 2017 Hamburg Summit with health as a priority on the agenda, hosted by Angela Merkel, the scientist. Canadian prime minister Justin Trudeau's mother had suffered from mental illness, specifically bipolar disorder. US president Donald Trump had family issues related to alcoholism, associated with the early death of his older brother Fred Trump Jr.

The first decrease in G20 health performance was at the 2015 Antalya Summit. The only G20 leaders associated with health issues were Brazil's Dilma Rousseff and Saudi Arabia's King Salman.

The second decrease in health was at the 2018 Buenos Aires Summit. Donald Trump and Justin Trudeau were at the summit.

Club at the Hub

The secretary general of the United Nations has attended every G20 summit. The WHO director general has attended none. This coincides with a G20 health performance that was small, save for the two spikes in 2014 and 2017.

At the G20 London Summit in 2009, leaders came from international organizations such as the Association of the South-East Asian Nations (ASEAN) represented by Secretary General Surin Pitsuwan, the Financial Stability Forum represented by Chair Mario Draghi, the IMF represented by Managing Director Dominique Strauss-Kahn, the World Bank represented by President Robert Zoellick, the United Nations represented by Security General Ban Ki-moon and the World Trade Organization (WTO) represented by Director General Pascal Lamy. Another participant was the New Partnership for Africa's Development (NEPAD) represented by Chair Meles Zenawi, who had dropped out of medical school to become the prime minister of Ethiopia (Guardian 2012).

After Robert Zoellick's term as president of the World Bank ended in 2012, Jim Young Kim was nominated to replace him by US president Barack Obama. A medical doctor, Kim had played a key role in global health and development, notably with his role in Partners in Health (Hayoun 2012).

During the first phase at the 2013 St. Petersburg Summit, with the largest number of words associated with health, guests included Spain's Prime Minister Mariano Rajoy, Brunei's Prime Minister Hassanal Bolkiah as a member of the Asia-Pacific Economic Cooperation (APEC) forum, Ethiopia's Prime Minister Hailemariam Desalegn as chair of the African Union (AU), Senegal's President Macky Sall as chair of NEPAD; Singapore's Prime Minister Lee Hsien Loong as chair of the Global Governance Group (3G), and Kazakhstan's President Nursultan Nazarbayev as a member of the Commonwealth of Independent States.

During the second phase at the 2014 Brisbane Summit, with the outbreak of the Ebola crisis, invited guests were Spain's Prime Minister Rajoy, Mauritius's President Mohamed Ould Abdel Aziz as AU chair, Myanmar's President Thein Sein as ASEAN chair, New Zealand's Prime Minister John Key, Senegal's President Macky Sall and NEPAD chair, and Singapore's Prime Minister Lee Hsien Loong as 3G chair.

During the third phase, at the 2017 Hamburg Summit where health was a summit priority, invited guests from international organizations included Jim Yong Kim of the World Bank, Mark Carney of the Financial Stability Board (FSB), Christine Lagarde of the IMF; António Guterres, UN secretary general, José Graziano da Silva of the Food and Agriculture Organization (FAO), Guy Ryder of the International Labour Organization, Roberto Azevêdo, Director of the World Trade Organization (WTO) and Angel Gurría, OECD secretary-general.

The global summit network of which the G20 is the hub has been expanded by the increase in UN summits on health. Two major ones came in 2016 and 2011, 2014 and 2018.

Antimicrobial Resistance

AMR occurs when microorganisms such as bacteria, viruses, fungi and parasites change in ways that render ineffective the medications used to cure the infections they cause. When the microorganisms become resistant to most antimicrobials they are often referred to as "superbugs." This is a major concern because a resistant infection may kill, can spread to others and impose huge costs to individuals and society. The prevalence of AMR for eight common bacteria in G20 countries has been estimated to have increased from about 18% in 2000 to 22% in 2014 (OECD, WHO, FAO and OIE (2017).

On 21 September 2016, the UN held a General Assembly High-Level Meeting (HLM) dedicated to health for the fourth time in history. It was convened by Peter Thomson, president of the 71st session of the General Assembly. AMR had become of the largest threats to global health and endangered human development (WHO 2016). The others that were prominent were HIV, NCDs and Ebola. Importantly, AMR occur naturally but is facilitated by the inappropriate use of medicines, for example, using antibiotics for viral infections such as colds or influenza, or sharing antibiotics. Low-quality medicines, wrong prescriptions, and poor infection prevention and control also encourage the development and spread of drug resistance. Lack of government commitment to address these issues, poor surveillance and diminishing arsenal of tolls to diagnose, treat and prevent also hinder the control of AMR.

Non-Communicable Diseases

The four main NCDs are cardiovascular disease, cancer, chronic lung disease and diabetes.

There were three HLMs on NCDs — in September 2011, July 2014 and September 2018. These three occasions presented an opportunity for the international community to take action against the epidemic, save millions of lives and enhance development initiatives. Health is therefore a shared task in a both national and global sense (Kirton & Kickbusch, 2019).

During the second HLM on NCDs on 10 July 2014, G20 members acknowledged that many countries, in particular developing countries, were struggling to move from commitment to action and, in this regard, reiterated the call upon G20 member states to consider implementing, as appropriate, within national contexts, policies and evidence-based, affordable, cost-effective, population-wide and multisectoral interventions, including a reduction of modifiable risk factors of NCDs as described in the Global Action Plan (UN General Assembly 2014).

The third HLM on NCDs took place on 27 September 2018 (WHO 2018; Espinosa Garcés 2018). The purpose of this meeting was to allow heads of state and government to conduct a comprehensive review of progress achieved in reducing the risk of dying prematurely from NCDs, as agreed at the first HLM in 2011 and reaffirmed at the second one in 2014 (WHO 2018). The progress that was achieved resulted in a political declaration pledging 13 actions to prevent and control NCDs. Country leaders agreed that national actions should encompass restrictions on smoking, unhealthy foods, alcohol and sugary drinks, including controls on the marketing of such products (Paul 2018).

Case Studies

Three critical case studies show in more detail that path of G20 health performance from the causes that are behind. The most significant G20 health summits have been the 2013 St. Petersburg Summit; 2014 Brisbane Summit and the 2017 Hamburg Summit, for their contributions to the G20's progressive governance of global health. A major decrease in health performance came at the 2016 Hangzhou Summit.

2013 St. Petersburg Summit

The 2013 St. Petersburg Summit in 2013 saw the greatest increase in G20 deliberation, direction setting and development of global governance on health from any previous years, from the 2008 Washington Summit to the 2012 Los Cabos Summit. The St. Petersburg Summit had 1,340 words dedicated to health. This was the highest of all G20 health summits in the decade from Washington 2008 to Buenos Aires 2018. Importantly, it had the largest development of global governance score of all the G20 summits.

With the outbreak of MERS, a viral respiratory disease caused by a novel coronavirus, in Saudi Arabia in 2012, the St. Petersburg Summit addressed the involvement of G20 leaders in epidemic outbreaks. Leaders agreed "to improve rapid and effective responses to the outbreak of new diseases that threaten human life and disrupt economic activity, we call on countries to strengthen compliance with the World Health Organization's International Health Regulations" (G20 2013). Because of this outbreak, the WHO had a large presence in addressing it by working with public health specialists, animal health specialists, clinicians and scientists in affected areas and countries and internationally to gather and share scientific evidence to better understand the virus and the disease it causes (WHO 2019). During the 2013 St. Petersburg Summit, MERS was a topic of discussion in order for the G20 to provide effective response to public health threats and to strengthen compliance with the WHO's regulations (White House 2013).

2014 Brisbane Summit

Following the St. Petersburg Summit, the 2014 Brisbane Summit had a second spike in the deliberations dedicated to health by addressing issues pertaining to health on the global scale with the outbreak of Ebola.

In November 2014, the G20 held its first summit since the Ebola outbreak. The death toll at this time was at its highest at 4,447 victims. Ebola symptoms of fever fatigue, muscle pain, headache and sore throat can be followed by more threatening symptoms if left untreated, which may cause death if left untreated. The outbreak of the Ebola virus in 2014 had the largest spread in three West African countries of Guinea, Sierra Leone and Liberia.

At the Brisbane Summit, amidst a large international response to Ebola, G20 leaders released a joint statement that recognized the serious humanitarian, social and economic impact of Ebola. With the WHO's slow response in reaction to the Ebola outbreak, G20 leaders committed to do what was necessary to ensure international effort could extinguish the outbreak and address its medium-term economic and humanitarian costs (G20 2014a). With the support of the AU, contributions given by the UN and its bodies such as the WHO, international and regional organizations, financial institutions, non-government and religious organizations, and the private sector, aid was still offered by the G20 leaders in response to WHO's failure (G20 2014a). Multilateral institutions such as the World Bank Group and the IMF were urged by the G20 leaders to continue their support for the affected countries and to donate aid of $300 million to stem the Ebola outbreak and ease pressure on Guinea, Liberia and Sierra Leone (G20 2014a). As such, the Ebola outbreak acted as a shock-activated vulnerability propagating future summits to commit to putting health on the agenda.

2017 Hamburg Summit

The third spike in G20 health performance came at the 2017 Hamburg Summit, where deliberations were again at an all-time high. Under Chancellor Angela Merkel's presidency, health for the first time became priority on the summit's agenda. Even though the communiqué did not specifically address the Ebola outbreak, it did address safeguarding against health crises and strengthening health systems including discussions regarding AMR and striving to fully eradicate polio (G20 2017). In addressing strengthening health systems, the G20 leaders emphasize the value of ongoing trust building and cross-sectoral cooperation. They supported universal health coverage as a goal adopted in the 2030 Agenda on Sustainable Development and recognized that strong health systems were important to effectively address health crises (G20 2017).

On health, the 2017 Hamburg Summit addressed the ongoing threats that AMR presented to public health and economic growth. In order to address this issue and take preventative measures against the spread of AMR in humans, animals and the environment, the G20 leaders aimed to have implementation of national action plans, based on a one-health approach (G20 2017).

Conclusions and Recommendations

In conclusion, the G20 has made valuable progress and contributions to global health governance through the increasing prominence of health on its agenda, its increasingly expansive governance of heath, and its support for other health-centred institutions led by the WHO. Throughout the two phases of the G20's global health governance, performance along most dimensions, notably deliberations during the 2013 St. Petersburg Summit, the 2014 Brisbane Summit and the 2017 Hamburg Summit, were generally strong. The first phase was defined by increasing engagement and a second phase defined by expansion and implementation. This led to the 2017 Hamburg Summit where health was put as a priority on the agenda, with an expansive scope and definition what global health governance consists of and how it should be addressed.

The G20's overall performance on health is not without its shortcomings. The most significant weakness is in direction setting on financial stability and in delivery. Thus, the most pressing recommendation that the G20 should take into account is to improve accountability mechanisms for compliance so that deliberative, decision making and direction setting are able to be translated into action and results on each of the G20 summits. The G20 has contributed to some significant achievements, notably, addressing and aiding control of the Ebola epidemic. Health was then inconsistently reinstated in subsequent summits as a priority. The one shock-activated vulnerability prompted by the Ebola outbreak in 2014 should not be the sole cause of health being put on the agenda.

The future of successful health governance is found in global health preparedness and consistency (Sainsbury and Wurf, 2015). Political action in response to global health security can no longer be episodic and reactive in nature. The G20 should not only focus on the health when an epidemic strikes but should maintain active agendas on health and working with institutions such as the UN, the WHO and the G7 to ensure preventative practice worldwide in order to ensure that Sustainable Development Goals are met by 2030.

As the 2019 Osaka Summit approached, questions regarding health and funding mechanisms arose (Warren 2019). To effectively tackle health issues, it was crucial that G20 members use this summit to overcome the barriers that have traditionally separated health experts and policymakers from financial and economic leaders (Johnson 2019). With this collaboration, direction setting on financial accountability should increase.

In all, the G20 has been an effective forum for taking action to protect the world against health risks, especially their consequences in a globalized world. Thus, although the G20 is well placed to respond to issues arising in international global health governance, it must develop its role beyond being a reactionary body and establish itself as a steering committee for global health governance, as it did at the 2017 Hamburg Summit. This includes setting priorities for health initiatives that include rich countries playing a lead role in helping poorer nations strengthen their health systems.

References

Gostin, Lawrence O. and Eric A. Friedman (2015). "A Retrospective and Prospective Analysis of the West African Ebola virus Disease Epidemic: Robust National Health Systems at the Foundation and an Empowered WHO at the Apex. The Lancet, vol. 385, no. 9980, pp. 1902-1909, https://doi.org/10.1016/S0140-6736(15)60644-4.

Gostin, Lawrence O., Oyewale Tomori, Suwit Wibulpolprasert et al. (2016). "Toward a Common Secure Future: Four Global Commissions in the Wake of Ebola." PLoS Medicine, vol. 13, no. 5, https://doi.org/10.1371/journal.pmed.1002042.

Kirton, John (2013). "Explaining G20 Summit Success." Paper prepared for a presentation to the Queensland Branch of the Australian Institute of International Affairs, Brisbane, Australia, 17 December. http://www.g20.utoronto.ca/biblio/kirton-aiia-2013.html.

Kirton, John, Caroline Bracht and Julia Kulik (2015). "Slowly Succeeding: G20 Social Policy Governance," in Alexandra Kaasch and Kerstin Martens, eds., Actors and Agency in Global Social Governance (Oxford: Oxford University Press), pp. 153-74.

Kirton, John and Ilona Kickbusch, eds. (2019). Health: A Political Choice (London: GT Media). http://bit.ly/2019UHC.

Kirton, John, Ella Kokotsis, Jenilee Guebert et al. (2019). "Summit Performance Assessment Manual." Global Governance Program, Trinity College, University of Toronto.

Kirton, John, Julia Kulik and Caroline Bracht (2014). "Generating Global Health Governance through BRICS Summitry," Contemporary Politics vol. 20, no. 2, pp. 146-162.

Kirton, John and Jenevieve Mannell (2007). "The G8 and Global Health Governance," in Andrew F. Cooper, John Kirton and Ted Schrecker, eds., Governing Global Health: Challenge, Response, Innovation (Aldershot: Ashgate).

Labonté, Ronald, Katia Mohindra and Ted Schrecker (2011). "The Growing Impact of Globalization for Health and Public Health Practice," Annual Review of Public Health vol. 2011, no. 32, pp. 263-283. doi: 10.1146/annurev-publhealth-031210-101225.

Organisation for Economic Co-operation and Development (2019). "Doctors (Indicator)." doi: 10.1787/4355e1ec-en (accessed on 17 April 2019).

United Nations (2011). "Leaders Gather at UN Headquarters for a High-Level Meeting on Non-communicable Diseases (NCDs)." 2011 High Level Meeting on Prevention and Control of Non-communicable Diseases, General Assembly, 19-20 September 2011. https://www.un.org/en/ga/ncdmeeting2011.

United Nations Development Programme (2018). "Current Health Expenditure (% of Gross Domestic Product)." Human Development Reports. http://hdr.undp.org/en/indicators/181806.

Warren, Brittaney (2019). "G20 Performance of Health," in John Kirton and Madeline Koch, eds., G20 Japan: The Osaka Summit (London: GT Media), pp. 104-05. http://bit.ly/G20Japan.

Appendix A: G20 Leaders Conclusions on Health, 2008-2018↩

Compiled by Zaria Shaw, Sarah Jane Vassallo, Julia Kulik, Maria Marchyshyn, Brett Donnelly and Duja Muhanna, G20 Research Group.

Data are drawn from all official English-language documents released by the G20 leaders as a group. Charts are excluded.

"# words" is the number of health-related subjects for the year specified, excluding document titles and references. Words are calculated by paragraph because the paragraph is the unit of analysis.

"% total words" refers to the total number of words in all documents for the year specified.

"#paragraphs" is the number of paragraphs containing references to health for the year specified. Each point is recorded as a separate paragraph.

"% total paragraphs" refers to the total number of paragraphs in all documents for the year specified.

"# documents" is the number of documents that contain health subjects and excludes dedicated documents.

"% total documents" refers to the total number of documents for the year specified.

"# dedicated documents" is the number of documents for the year that contain a health-related subject in the title.

Introduction

This report catalogues all G20 final statements, referred to as "conclusions", related to the issue area of health. It refers to all official statements and annexes released by the leaders, as a group, at each G20 leaders' summit since their beginning in 2008 to the present.

Definition of Issue Area

Health is defined as the human condition of being sound in mind, body and spirit, and being free from physical disease or pain. This definition becomes more complex when health is considered in terms of its economic effect, as is the case with the heavy burden of HIV/AIDS in sub-Saharan Africa. The G20 are working to support the health-related Millennium Development Goals and to ensure more equitable, affordable and available healthcare for populations worldwide.

Search Terms

Inclusions

Antiretroviral treatment, avian influenza (flu), biological pathogen, bird influenza (flu), cholera, communicable diseases, disease, DNA, drugs (medical), Ebola, epidemic, famine, guinea worm, health, healthcare, HIV/AIDS, human influenza (flu), hunger, infectious disease, malaria, malnutrition, measles, Millennium Development Goals (MDGs), non-communicable diseases (NCDs), pandemic, pneumonia, polio, river blindness, severe acute respiratory syndrome (SARS), tuberculosis, vaccine, virus, World Health Assembly (WHA), World Health Organization (WHO).

Exclusions

Coding Rules

Cognate or extended terms can be used without a direct reference to "health" if they have previously been directly associated together in summit document history.

2008: Washington DC, November 14-15

Declaration of the Summit on Financial Markets and the World Economy

Commitment to an Open Global Economy

14. We are mindful of the impact of the current crisis on developing countries, particularly the most vulnerable. We reaffirm the importance of the Millennium Development Goals, the development assistance commitments we have made, and urge both developed and emerging economies to undertake commitments consistent with their capacities and roles in the global economy. In this regard, we reaffirm the development principles agreed at the 2002 United Nations Conference on Financing for Development in Monterrey, Mexico, which emphasized country ownership and mobilizing all sources of financing for development.

15. We remain committed to addressing other critical challenges such as energy security and climate change, food security, the rule of law, and the fight against terrorism, poverty and disease.

2009: London, April 1-2

Global Plan for Recovery and Reform

Ensuring a fair and sustainable recovery for all

We are determined not only to restore growth but to lay the foundation for a fair and sustainable world economy…. To this end:

2009: Pittsburgh, September 24-25

Global Plan for Recovery and Reform

Strengthening Support for the Most Vulnerable

34. Many emerging and developing economies have made great strides in raising living standards as their economies converge toward the productivity levels and living standards of advanced economies…. We note with concern the adverse impact of the global crisis on low income countries' (LICs) capacity to protect critical core spending in areas such as health, education, safety nets, and infrastructure. The UN's new Global Impact Vulnerability Alert System will help our efforts to monitor the impact of the crisis on the most vulnerable. We share a collective responsibility to mitigate the social impact of the crisis and to assure that all parts of the globe participate in the recovery.

37. We reaffirm our historic commitment to meet the Millennium Development Goals and our respective Official Development Assistance (ODA) pledges, including commitments on Aid for Trade, debt relief, and those made at Gleneagles, especially to sub-Saharan Africa, to 2010 and beyond.

2010: Toronto, September 26-27

The G20 Toronto Summit Declaration

Other Issues and Forward Agenda

44. We recognize that 2010 marks an important year for development issues. The September 2010 Millennium Development Goals (MDG) High Level Plenary will be a crucial opportunity to reaffirm the global development agenda and global partnership, to agree on actions for all to achieve the MDGs by 2015, and to reaffirm our respective commitments to assist the poorest countries.

Annex I: The Framework for Strong, Sustainable and Balanced Growth

12. Surplus economies will undertake reforms to reduce their reliance on the external demand and focus more on domestic sources of growth…Emerging surplus economies will undertake reforms tailored to country circumstances to:

2010: Seoul, November 11-12

G20 Seoul Summit Leaders' Declaration

The Seoul Summit Document

The Seoul Action Plan

10. Structural Reforms: We will implement a range of structural reforms to boost and sustain global demand, foster job creation, contribute to global rebalancing, and increase our growth potential, and where needed undertake:

Seoul Development Consensus for Shared Growth

46. The crisis disproportionately affected the most vulnerable in the poorest countries and slowed progress toward achievement of the Millennium Development Goals (MDGs). As the premier economic forum, we recognize the need to strengthen and leverage our development efforts to address such challenges.

53. We reaffirm our commitment to achievement of the MDGs and will align our work in accordance with globally agreed development principles for sustainable economic, social and environmental development, to complement the outcomes of the UN High-Level Plenary Meeting on the MDGs held in September 2010 in New York, as well as with processes such as the Fourth UN LDC Summit in Turkey and the Fourth High-Level Forum on Aid Effectiveness in Korea, both to be held in 2011. We also reaffirm our respective ODA pledges and commitments to assist the poorest countries and mobilize domestic resources made following on from the Monterrey Consensus and other fora.

Annex I: Seoul Development Consensus for Shared Growth

Annex II: Multi-Year Action Plan on Development

Developing human capital is a critical component of any country's growth and poverty reduction strategy. Adding to education initiatives related to the Millennium Development Goals (MDGs), it is important for developing countries, in particular LICs, to continue to develop employment-related skills that are better matched to employer and market needs in order to attract investment and decent jobs.

2011: Cannes, November 3-4

Cannes Summit Final Declaration – Building Our Common Future: Renewed Collective Action for the Benefit of All

Fostering Employment and Social Protection

4. We recognize the importance of investing in nationally determined social protection floors in each of our countries, such as access to health care, income security for the elderly and persons with disabilities, child benefits and income security for the unemployed and assistance for the working poor. They will foster growth resilience, social justice and cohesion. In this respect, we note the report of the Social Protection Floor Advisory Group, chaired by Ms Michelle Bachelet.

Addressing Food Price Volatility and Increasing Agriculture Production and Productivity

40. Increasing agricultural production and productivity is essential to promote food security and foster sustainable economic growth. A more stable, predictable, distortion free, open and transparent trading system allows more investment in agriculture and has a critical role to play in this regard. Mitigating excessive food and agricultural commodity price volatility is also an important endeavour. These are necessary conditions for stable access to sufficient, safe and nutritious food for everyone. We agreed to mobilize the G20 capacities to address these key challenges, in close cooperation with all relevant international organisations and in consultation with producers, civil society and the private sector.

49. We welcome the production of a report by the international organizations on how water scarcity and related issues could be addressed in the appropriate fora.

Development: Investing for Global Growth

73. Investing in infrastructure in developing countries, especially in LICs and, whilst not exclusively, with a special emphasis on sub-Saharan Africa, will unlock new sources of growth, contribute to the achievement of the Millennium Development Goals and sustainable development. We support efforts to improve capacities and facilitate the mobilization of resources for infrastructure projects initiated by public and private sectors.

Communiqué: G20 Leaders Summit

Addressing the Challenges of Development

28. In order to meet the Millennium Development Goals, we stress the pivotal role of ODA. Aid commitments made by developed countries should be met. Emerging countries will engage or continue to extend their level of support to other developing countries. We also agree that, over time, new sources of funding need to be found to address development needs and climate change. We discussed a set of options for innovative financing highlighted by Mr Bill Gates. Some of us have implemented or are prepared to explore some of these options. We acknowledge the initiatives in some of our countries to tax the financial sector for various purposes, including a financial transaction tax, inter alia to support development.

Cannes Action Plan for Growth and Jobs

Strengthening the Medium-term Foundations for Growth

6. While reducing barriers to trade and investment will help reduce the development gap and support progress towards the Millennium Development Goals, further efforts to support capacity building and channelling of surplus savings for growth-enhancing investments in developing countries, including infrastructure development, would also have positive spillovers for global growth, rebalancing and development.

2012: Los Cabos, June 18-19

Declaration of the Summit on Financial Markets and the World Economy

Meeting the Challenges of Development

63. Eradicating poverty and achieving strong, inclusive, sustainable and balanced growth remain core objectives of the G20 development agenda. We reaffirm our commitment to work with developing countries, particularly low income countries, and to support them in implementing the nationally driven policies and priorities which are needed to fulfill internationally agreed development goals, particularly the Millennium Development Goals (MDGs) and beyond.

67. We reaffirm our commitments to the global partnership for development, as set out in the MDGs, and welcome efforts to contribute to this end, including the Global Partnership for Effective Development Cooperation to be launched with voluntary participation under the auspices of the broad consensus achieved at the 4th High Level Forum on Aid Effectiveness held in Busan, Korea.

The Los Cabos Growth and Jobs Action Plan

Strengthening the Medium-term Foundations for Growth

2. We will intensify our efforts to rebalance global demand, through increasing domestic demand in countries with current account surpluses, rotating demand from the public to private sector in countries with fiscal deficits and increasing national savings in countries with current account deficits.

2014: Brisbane, November 15-16

G20 Leaders' Communiqué

Acting Together to Lift Growth and Create Jobs

10. We are strongly committed to reducing youth unemployment, which is unacceptably high, by acting to ensure young people are in education, training or employment. Our Employment Plans include investments in apprenticeships, education and training, and incentives for hiring young people and encouraging entrepreneurship. We remain focused on addressing informality, as well as structural and long-term unemployment, by strengthening labour markets and having appropriate social protection systems. Improving workplace safety and health is a priority. We ask our labour and employment ministers, supported by an Employment Working Group, to report to us in 2015.

Strengthening Global Institutions

20. We are deeply concerned with the humanitarian and economic impact of the Ebola outbreak in Guinea, Liberia and Sierra Leone. We support the urgent coordinated international response and have committed to do all we can to contain and respond to this crisis. We call on international financial institutions to assist affected countries in dealing with the economic impacts of this and other humanitarian crises, including in the Middle East.

Brisbane Action Plan

G20 Leaders' Statement on Ebola

We are deeply concerned about the Ebola outbreak in Guinea, Liberia and Sierra Leone and saddened by the suffering and loss of life it is inflicting. We are mindful of the serious humanitarian, social and economic impacts on those countries, and of the potential for these impacts to spread.

The governments and people of Guinea, Liberia and Sierra Leone are making tremendous efforts to fight the outbreak, with the support of the African Union and other African countries. We commend the brave service of health care and relief workers. We also applaud the contributions of countries worldwide, the United Nations (UN) and its bodies such as the World Health Organization (WHO), international and regional organisations and financial institutions, non-governmental and religious organisations, and the private sector. We fully support the UN Mission for Ebola Emergency Response's ongoing work to harness capacity to stop the outbreak, treat the infected, ensure essential services, preserve stability and prevent further outbreaks and urge that it act swiftly to achieve these objectives.

G20 members are committed to do what is necessary to ensure the international effort can extinguish the outbreak and address its medium-term economic and humanitarian costs. We will work through bilateral, regional and multilateral channels, and in partnership with non-governmental stakeholders. We will share our experiences of successfully fighting Ebola with our partners, including to promote safe conditions and training for health care and relief workers. We will work to expedite the effective and targeted disbursement of funds and other assistance, balancing between emergency and longer-term needs.

We invite those governments that have yet to do so to join in providing financial contributions, appropriately qualified and trained medical teams and personnel, medical and protective equipment, and medicines and treatments. While commending ongoing work, we urge greater efforts by researchers, regulators and pharmaceutical companies to develop safe, effective and affordable diagnostic tools, vaccines and treatments. We call upon international and regional institutions, civil society and the private sector to work with governments to mitigate the impacts of the crisis and ensure the longer-term economic recovery.

In this regard, we urge the World Bank Group (WBG) and International Monetary Fund (IMF) to continue their strong support for the affected countries and welcome the IMF's initiative to make available a further $300 million to stem the Ebola outbreak and ease pressures on Guinea, Liberia and Sierra Leone, through a combination of concessional loans, debt relief, and grants. We ask the IMF and WBG to explore new, flexible mechanisms to address the economic effects of future comparable crises.

This outbreak illustrates the urgency of addressing longer-term systemic issues and gaps in capability, preparedness and response capacity that expose the global economy to the impacts of infectious disease. G20 members recommit to full implementation of the WHO's International Health Regulations (IHR). To this end, and in the context of our broader efforts to strengthen health systems globally, we commit to support others to implement the IHR and to build capacity to prevent, detect, report early and rapidly respond to infectious diseases like Ebola. We also commit to fight anti-microbial resistance. Interested G20 members are supporting this goal through initiatives to accelerate action across the Economic Community of West African States and other vulnerable regions and will report progress and announce a time frame by May 2015 at the World Health Assembly.

We invite all countries to join us in mobilising resources to strengthen national, regional and global preparedness against the threat posed by infectious diseases to global health and strong, sustainable and balanced growth for all. We will remain vigilant and responsive.

2015: Antalya, November 15-16

G20 Leaders' Communiqué

7. Unemployment, underemployment and informal jobs are significant sources of inequality in many countries and can undermine the future growth prospects of our economies. We are focused on promoting more and better quality jobs in line with our G20 Framework on Promoting Quality Jobs and on improving and investing in skills through our G20 Skills Strategy. We are determined to support the better integration of our young people into the labour market including through the promotion of entrepreneurship. Building on our previous commitments and taking into account our national circumstances, we agree to the G20 goal of reducing the share of young people who are most at risk of being permanently left behind in the labour market by 15% by 2025 in G20 countries. We ask the OECD and the ILO to assist us in monitoring progress in achieving this goal. We will continue monitoring the implementation of our Employment Plans as well as our goals to reduce gender participation gap and to foster safer and healthier workplaces also within sustainable global supply chains.

Issues for Further Action

We agree that attention should be given to global health risks, such as antimicrobial resistance, infectious disease threats and weak health systems. These can significantly impact growth and stability. Building on the Brisbane Statement, we underscore the importance of a coordinated international response and reiterate our resolve to tackle these issues to fight the adverse impacts on the global economy and will discuss the terms of reference to deal with this issue in the G20 next year.

Antalya Action Plan

Promoting Employment Opportunities for All

The quality of jobs is another vital aspect of the issue as it directly affects the well-being of individuals. Women and youth are among the most vulnerable groups in terms of quality of jobs as they are at risk of informality and low pay. To tackle these problems we agreed on a G20 Framework on Promoting Quality Jobs that includes measures in the areas of promoting the quality of earnings, reducing labor market insecurity and encouraging good working conditions and healthy work places.

G20 Action Plan on Food Security and Sustainable Food Systems

We, the G20 Leaders are committed to addressing the challenge of improving global food security, nutrition and the sustainability of food systems. Although more than half of developing countries have reached the Millennium Development Goal target of halving the proportion of people suffering from hunger, the Food and Agriculture Organization estimates there are still 795 million people undernourished. Global food supply will need to increase by 60 percent to feed a projected world population of 9.7 billion people by 2050. We recognize that to improve food security and nutrition in the face of intensifying pressures on natural resources and the impacts of climate change, we will need to increase productivity while simultaneously building food systems that are more sustainable and resilient.

2016: Hangzhou, September 4-5

G20 Leaders' Communiqué

46. Antimicrobial resistance (AMR) poses a serious threat to public health, growth and global economic stability. We affirm the need to explore in an inclusive manner to fight antimicrobial resistance by developing evidence-based ways to prevent and mitigate resistance, and unlock research and development into new and existing antimicrobials from a G20 value-added perspective, and call on the WHO, FAO, OIE and OECD to collectively report back in 2017 on options to address this including the economic aspects. In this context, we will promote prudent use of antibiotics and take into consideration huge challenges of affordability and access of antimicrobials and their impact on public health. We strongly support the work of the WHO, FAO and the OIE and look forward to a successful high-level meeting on AMR during the UN General Assembly. We look forward to the discussion under the upcoming presidency for dealing with these issues.

2016 Hangzhou Action Plan

Members' commitments to advance labour market reform, educational attainment and skills include:

Saudi Arabia is introducing a national program for occupational health and safety.

India is introducing a health insurance scheme which will protect one-third of the country's population against hospitalization expenditures.

Members' commitments to promote competition and an enabling environment include:

Japan is promoting the use of robotics, Big data, IoT to R&D, diagnosis, examination, and nursery in the health industry, aiming for the expansion of its market.

2017: Hamburg, July 7-8

G20 Leaders' Declaration: Shaping an Interconnected World

Preamble:

We are resolved to tackle common challenges to the global community, including terrorism, displacement, poverty, hunger and health threats, job creation, climate change, energy security, and inequality including gender inequality, as a basis for sustainable development and stability. We will continue to work together with others, including developing countries, to address these challenges, building on the rules-based international order.

Safeguarding against Health Crises and Strengthening Health Systems: The G20 has a crucial role in advancing preparedness and responsiveness against global health challenges. With reference to the results of the G20 health emergency simulation exercise, we emphasise the value of our ongoing, trust-building, cross-sectoral cooperation. We recall universal health coverage is a goal adopted in the 2030 Agenda and recognize that strong health systems are important to effectively address health crises. We call on the UN to keep global health high on the political agenda and we strive for cooperative action to strengthen health systems worldwide, including through developing the health workforce. We recognise that implementation of and compliance with the International Health Regulations (IHR 2005) is critical for efficient prevention, preparedness and response efforts. We strive to fully eradicate polio. We also acknowledge that mass movement of people can pose significant health challenges and encourage countries and International Organisations to strengthen cooperation on the topic. We support the WHO´s central coordinating role, especially for capacity building and response to health emergencies, and we encourage full implementation of its emergency reform. We advocate for sufficient and sustainable funding to strengthen global health capacities, including for rapid financing mechanisms and the WHO's Health Emergencies Programme. Furthermore, we see a need to foster R&D preparedness through globally coordinated models as guided by the WHO R&D Blueprint, such as the Coalition for Epidemic Preparedness Innovations (CEPI).

Combatting Antimicrobial Resistance (AMR): AMR represents a growing threat to public health and economic growth. To tackle the spread of AMR in humans, animals and the environment, we aim to have implementation of our National Action Plans, based on a One-Health approach, well under way by the end of 2018. We will promote the prudent use of antibiotics in all sectors and strive to restrict their use in veterinary medicine to therapeutic uses alone. Responsible and prudent use of antibiotics in food producing animals does not include the use for growth promotion in the absence of risk analysis. We underline that treatments should be available through prescription or the veterinary equivalent only. We will strengthen public awareness, infection prevention and control and improve the understanding of the issue of antimicrobials in the environment. We will promote access to affordable and quality antimicrobials, vaccines and diagnostics, including through efforts to preserve existing therapeutic options. We highlight the importance of fostering R&D, in particular for priority pathogens as identified by the WHO and tuberculosis. We call for a new international R&D Collaboration Hub to maximise the impact of existing and new anti-microbial basic and clinical research initiatives as well as product development. We invite all interested countries and partners to join this new initiative. Concurrently, in collaboration with relevant experts including from the OECD and the WHO, we will further examine practical market incentive options.

G20 Hamburg Climate and Energy Action Plan for Growth

In facilitating well-balanced and economically viable long-term strategies and signals for investments in order to continually transform and enhance our economies and energy systems, G20 members will collaborate closely and balance a number of important factors, including inter alia energy security, energy access, infrastructure, environmental protection, poverty reduction, good health, quality education and quality job creation.

Hamburg Update: Taking Forward the G20 Action Plan on the 2030 Agenda for Sustainable Development

G20 Digital Economy Development and Cooperation Initiative Global Health

2018: Buenos Aires, November 30 – December 1

G20 Leaders' Declaration

15. We encourage the activities of World Health Organization (WHO), together with all relevant actors, to develop an action plan for implementation of health-related aspects of SDGs by 2030. We commend the progress made by the international community in developing and implementing National and Regional Action Plans on Anti-Microbial Resistance (AMR) based on One-Health approach. We recognize the need for further multi-sectoral action to reduce the spread of AMR, as it is increasingly becoming a global responsibility. We note the work done by the Global AMR R&D Hub and, drawing on this, we look forward to further examine practical market incentives. We will tackle malnutrition, with a special focus on childhood overweight and obesity, through national, community-based and collaborative multi-stakeholder approaches. We reaffirm the need for stronger health systems providing cost effective and evidence-based intervention to achieve better access to health care and to improve its quality and affordability to move towards Universal Health Coverage (UHC), in line with their national contexts and priorities. This may encompass, where appropriate, scientifically proven traditional and complementary medicine, assuring the safety, quality and effectiveness of health services. We will continue to strengthen core capacities required by International Health Regulations (IHR, 2005) for prevention, detection and response to public health emergencies, while recognizing the critical role played by WHO in this regard. We are committed to ending HIV/AIDS, tuberculosis and malaria, and look forward to a successful 6° replenishment of the Global Fund in 2019.

Buenos Aires Action Plan

Appendix B: G20 Health Performance, 2008-2018↩

MDG = assessment referred to a health-related Millennium Development Goal. n/a = Not applicable.

Domestic political management is measured by the number of leaders in attendance at the summit and the number of times a country or leader was positively mentioned in the outcome document(s) in a health-related context.

Deliberation is measured by the number of words on the subject in the outcome document(s) and the percentage of total words, and the number of health-related outcome documents.

Direction setting is measured by the number of references to the G20's foundational mission of financial stability, equality, democracy and human rights in a health-related context.

Decisions is measured by the number of health commitments and the percentage of overall commitments.

Delivery is measured by compliance with health commitments and the number of compliance reports assessed.

Development of global governance is measured by the meetings of health ministers, and number of references to health-related governance mechanisms within the G20 (inside) and outside the G20.

Appendix C: G20 Commitments by Subject, 2008-2016 ↩

Appendix D: Communiqué Recognized Health Shocks and Vulnerabilities ↩

Appendix E: G20 Members' Specialized Capabilities in Health ↩

Per capita expenditure: For all countries except Argentina, Saudi Arabia and the European Union. US dollars/capita, 2017 or latest year available.

This Information System is provided by the University of Toronto Library
and the G20 Research Group at the University of Toronto.

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This page was last updated November 19, 2019 .

Issue area (rank)	Total commitments assessed of total made		Compliance
Issue area (rank)	Total commitments assessed of total made		Score	Percentage
Microeconomics (15)	1 of 10	10.0%	+1.00	100
Infrastructure (14)	1 of 36	2.8%	+0.95	98
Terrorism (15)	2 of 16	12.5%	+0.73	87
Macroeconomics (1)	23 of 402	5.8%	+0.60	80
Migration and refugees (7)	1 of 7	14.3%	+0.60	80
Labour and employment (7)	16 of 100	16.0%	+0.55	78
Health (13)	4 of 38	10.5%	+0.53	77
Financial regulation (2)	20 of 271	7.4%	+0.50	75
Energy (6)	16 of 106	15.1%	+0.45	73
Food and agriculture (9)	6 of 64	9.4%	+0.39	70
Gender (18)	5 of 6	83.3%	+0.41	71
Reform of international financial institutions (5)	5 of 120	4.2%	+0.34	67
Development (3)	45 of 193	23.3%	+0.32	66
Climate change (10)	22 of 53	42.0%	+0.29	65
Trade (4)	14 of 133	11.0%	+0.26	63
International cooperation (12)	2 of 39	5.1%	+0.15	58
Crime and corruption (8)	7 of 78	9.0%	+0.14	57
Information and communications technology (11)	1 of 49	2.0%	+0.10	55
Total/Average	191 of 1,863	10.4%	+0.41	71

Country	Per capita expenditures	GDP share %	Doctors	Nurses
G7
Canada	4,826	10.4%	2.7	9.9
France	4,902	11.4%	3.3	10.4
Germany	5,728	11.3%	4.1	12.8
Italy	3,542	8.9%	4.0	6.5
Japan	4,717	10.7%	2.4	11.3
United Kingdom	4,246	9.6%	2.8	7.8
United States	10,209	17.1%	2.5	11.6
European Union
BRICS
Brazil	1,402	8.9%
Russia	1,305	5.2%	3.9	8.4
India	238	3.8%	0.7	1.3
China	762	5.4%	1.8	2.3
South Africa	1,090	8.1%	0.7	1.2
Global share (%)
MIKTA
Mexico	1,034	5.4%	2.3	2.8
Indonesia	383	3.4%
Korea	2,897	7.5%	2.3	6.9
Turkey	1,194	4.2%	1.8	1.9
Australia		9.1%	3.5	11.6
Global share (%)
G20
Argentina
Australia	4,543	9.1%	3.5	11.6
Brazil	1,402	8.9%
Canada	4,826	10.4%	2.7	9.9
China	762	5.4%	1.8	2.3
France	4,902	11.4%	3.3	10.4
Germany	5,728	11.3%	4.1	12.8
India	238	3.8%	0.7	1.3
Indonesia	383	3.4%
Italy	3,542	8.9%	4.0	6.5
Japan	4,717	10.7%	2.4	11.3
Korea	2,897	7.5%	2.3	6.9
Mexico	1,034	5.4%	2.3	2.8
Russia	1,305	5.2%	3.9	8.4
Saudi Arabia
South Africa	1,090	8.1%	0.7	1.2
Turkey	1,194	4.2%	1.8	1.9
United Kingdom	4,246	9.6%	2.8	7.8
United States	10,209	17.1%	2.5	11.6
European Union
Global share (%)

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Year	# words	% total words	# paragraphs	% total paragraphs	# documents	% total documents	# dedicated documents
2008 Washington	118	3	2	24	1	50	0
2009 London	59	1	2	1	1	33	0
2009 Pittsburgh	284	3	5	4	1	33	0
2010 Toronto	139	1	2	1	1	25	0
2010 Seoul	643	4	10	3	4	80	0
2011 Cannes	470	3	6	4	3	100	0
2012 Los Cabos	250	2	4	2	2	50	0
2013 St. Petersburg	1,340	5	12	2	5	45	0
2014 Brisbane	769	8	10	5	3	60	1
2015 Antalya	481	3	4	1	3	50	0
2016 Hangzhou	234	1	4	1	4	100	0
2017 Hamburg	707	2	8	0	3	30	0
2018 Buenos Aires	316	4	3	2	2	100	0
Total	5,810	40	72	50	33	756	1
Average	447	3	6	4	3	58	0

Year	Domestic political management		Deliberation			Direction setting				Decision making		Delivery		Development of global governance
	Attendance	Communiqué compliments	Words		Documents	Financial stability	Equality	Democracy	Human rights	Commitments	% all	Compliance	# commitments assessed	Ministerials	Inside	Outside
	Attendance	Communiqué compliments	#	%	Documents	Financial stability	Equality	Democracy	Human rights	Commitments	% all	Compliance	# commitments assessed	Ministerials	Inside	Outside
2008 Washington	100%	0	118	3.2	1	0	0			0	0	-	-	0	0	1
2009 London	100%	0	59	0.9	1	0	0			0	0	−0.05 (MDG)	1	0	0	0
2009 Pittsburgh	100%	0	284	3	1	0	0			0	0	+0.41 (MDG)	2	0	0	1
2010 Toronto	90%	0	139	1.2	1	0	1			0	0	-	-	0	0	0
2010 Seoul	95%	0	643	4.1	4	0	1			0	0	+0.19 (MDG)	1	0	1	7
2011 Cannes	95%	0	470	2.9	3	0	1			1	0.4	-	-	0	0	0
2012 Los Cabos	95%	1	250	1.9	2	0	0			1	1	-	-	0	0	0
2013 St. Petersburg	90%	0	1,340	11.2	5	0	2			0	0	-	-	0	5	5
2014 Brisbane	90%	0	769	8.4	3	0	1			33	16	+0.53	4	0	0	9
2015 Antalya	90%	0	481	3.5	3	0	1			2	1.7	+0.30	2	0	0	3
2016 Hangzhou	100%	0	234	1.4	4	0	0			3	1.4	-	-	0	0	7
2017 Hamburg	95%	0	707	2	3	0	1			19	3.6	+0.95	1	1	2	10
2018 Buenos Aires	90%	0	316	4	2	0	2			4	0.03	-	n/a	1	0	2
Total	n/a	1	5,810	n/a	33	0	10			61	n/a	n/a	11	2	6	45
Average	95%	n/a	447	3.7	2.5	0	0			4.8	1.9	+0.39	n/a		0.6	3.5

Year	Shock	Vulnerability
2008 Washington	1	1
2009 London	0	0
2009 Pittsburgh	3	0
2010 Toronto	0	0
2010 Seoul	0	1
2011 Cannes	0	0
2012 Los Cabos	0	0
2013 St. Petersburg	2	4
2014 Brisbane	2	1
2015 Antalya	1	1
2016 Hangzhou	1	0
2017 Hamburg	3	0
2018 Buenos Aires	0	0